Chandigarh

DF-I

CC/116/2024

GUNEETY ARORA - Complainant(s)

Versus

ICICI LOMBARD GENERAL INSURANCE CO LTD - Opp.Party(s)

GURPREET SINGH

05 Nov 2024

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-I,

U.T. CHANDIGARH

                                     

Consumer Complaint No.	:	CC/116/2024
Date of Institution	:	28.02.2024
Date of Decision	:	5/11/2024

 

Guneety Arora wife of Harpreet Singh Arora R/o House No. 1243, Sector 19-B Chandigarh

….Complainant

VERSUS

1.       ICICI Lombard General Insurance Company Ltd through its Branch Manager, Fourth Floor, The Statement, Plot No 149, Industrial Area, Phase 1, Next to Hometel Hotel, Chandigarh (UT)-160002

 

2.       CHD CITY HOSPITAL Pvt. Ltd. Through its authorized person, SCO No.10-11, Sector 8-C, Madhya Marg Chandigarh 160009

...Opposite Parties

 

CORAM :	SHRI PAWANJIT SINGH	PRESIDENT
	MRS. SURJEET KAUR	MEMBER
	SHRI SURESH KUMAR SARDANA	MEMBER

 

                                                                               

ARGUED BY	:	Sh.Gurpreet Singh, Advocate for complainant
	:	Sh.Ankur Gupta, Advocate for OP No.1
		Sh.P.P.S.Brar, Advocate for OP No.2 (defence of OP No.2 struck off).

Per Pawanjit Singh, President

1.         The present consumer complaint has been filed by the complainant under Section 35 of the Consumer Protection Act 2019 against the opposite parties  (hereinafter referred to as the ‘OPs’). The brief facts of the case are as under :-
   1. It transpires from the averments as projected in the consumer complaint that on 08.05.2021, the husband of the complainant, being impressed by the tall claims made the agent of OP No.1, opted for the purchase of Medical Insurance Policy on 08.05.2021 by the name of ICICI Lombard Nibhaye Vaade Plan, having a coverage of Rs.10 lacs, vide policy effective from 08.05.2021 to 07.05.2022 (Annexure C-1).  Vide policy (Annexure C-1), the complainant and her son were also insured in addition to the husband of the complainant. The aforesaid policy was renewed on 07.05.2022 and again renewed on 08.05.2023 (hereinafter referred to as the ‘subject policy) by paying the annual premium amount of Rs.19,966/-.  A copy of the subject policy is Annexure C-10. On 07.10.2022,  the complainant was feeling unwell and, therefore, she immediately visited the doctor who prescribed medicines and asked for certain tests vide prescription slip (Annexure C-2). On the next day i.e. 08.10.2022 as the condition of the complainant worsened, she immediately went to Chandigarh City Hospital, Madhya Marg, Chandigarh i.e. OP No.2 and after examining and considering her serious condition, the attending doctor immediately admitted the complainant as she was suffering from high-grade fever, headache, epigastric & abdominal discomfort, nausea, severe bodily pain, joint pain, burning sensation urine, oral ulcers etc. and was not able to eat because of oral pain and ulcers. OP No.2 is an empanelled hospital of OP No.1. At the time of admission in the hospital, the complainant gave details of the medical insurance policy and accordingly, OP No.2 informed OP No.1. The triage and H&P sheet dated 8/10/2022 is Annexure C-3.  On 09.10.2022, OP No.1 wrote to OP No.2 regarding the denial of cashless access due to inability to ascertain the liability of claim (Annexure C-4). Thereafter the husband of the complainant called at the call center of OP No.1 and tried to get in touch with the officials of OP No.1 but was unable to get any reasonable explanation regarding the denial to cashless claim. Thereafter, the husband of the complainant met Senior Manager, Sh.Balwinder of OP No.1 who informed that he will send a person to inspect and examine the complainant in the hospital.  On 10/10/2022, the investigator namely Sh.Ravi investigated & examined the condition of the complainant in the hospital and had also taken her photograph and got filled the form. The complainant was discharged on 12/10/2022 (Annexure C-5). Thereafter, the complainant followed up the treatment and visited the OPD on 14/10/2022, 27/10/2022, 23/1/2023. The copies of the prescription slips are Annexure C-6(Colly). Subsequently, the complainant lodged the claim with OP No.1 vide letter dated 28.10.2022, by submitting all the original documents and bills to the tune of ₹68,898/- for the reimbursement (Annexure C-7). However, OP No.1 illegally rejected the genuine claim vide letter dated 24.11.2022 (Annexure C-8) on the flimsy ground that the treatment of the complainant was possible on OPD basis.  The aforesaid act amounts to deficiency in service and unfair trade practice on the part of OP No.1. OP No.1 was requested several times to admit the claim, but, with no result.  Hence, the present consumer complaint.
   2. OP No.1 resisted the consumer complaint and filed its written version, inter alia, taking preliminary objections of maintainability, jurisdiction and  cause of action.  However, it is alleged that as per the terms and conditions of the insurance policy, the hospital means admission in a hospital for a minimum period of 24 consecutive ‘inpatient care” hours except for specific procedures/treatments. As the medical condition of the complainant is also not listed under specified day care procedures/treatment, the claim was rightly repudiated especially when no electrolyte imbalance note, no positive fever profile and no USG was done for abdominal pain.  On merits, the facts as stated in the preliminary objections have been re-iterated. It has further been alleged that the claim was rightly repudiated as the medical condition of the complainant did not require any hospitalization as she was only diagnosed with viral fever. The cause of action set up by the complainant is denied.  The consumer complaint is sought to be contested.
   3. In rejoinder, the complainant reiterated  the claim put forth in the consumer complaint and prayer has been made that the consumer complaint be allowed as prayed for.
   4. Pursuant to the notice issued by this Commission, OP No.2 put in appearance, but, as they failed to file reply within the stipulated period, therefore, their defence was struck off vide order dated 24.05.2024.
2.        In order to prove their respective claims the contesting parties have tendered  their evidence by way of respective affidavits and supporting documents.
3.        We have heard the learned counsel for the contesting parties and also gone through the file carefully, including the written arguments on record.
   1. At the very outset, it may be observed that when it is an admitted case of the parties that the complainant along with her husband and son were insured under the subject policy with coverage of ₹10.00 lakhs, as is also evident from the policy (Annexure C-10) and the complainant had taken treatment from OP No.2, where she was hospitalized /remained admitted w.e.f. 08.10.2022 to 12.10.2022, as is also evident from the discharge summary (Annexure C-5) and OP No.1 had firstly denied the cashless facility to the complainant as is also evident from the cashless denial letter (Annexure C-4) and when the claim was lodged by the complainant after her discharge from the hospital, the same was repudiated by OP No.1 vide repudiation letter (Annexure C-8),  the case is reduced to a narrow compass as it is to be determined if OP No.1 was not justified in repudiating the claim and the complainant is entitled to the reliefs prayed for in the consumer complaint, as is the case of the complainant, or if OP No.1 was justified in repudiating the claim of the complainant and the complaint of the complainant, being false and frivolous, is liable to be dismissed, as is the defence of the OPs.
   2. In the back drop of the foregoing admitted and disputed facts on record, one thing is clear that the entire case of the contesting parties is revolving around terms and conditions of the insurance policy (Annexure C-10), medical record and the repudiation letter (Annexure C-8) and the same are required to be scanned carefully.
   3. Perusal of the discharge summary (Annexure C-5) clearly indicates that the complainant admitted in OP No.2/Hospital on 08.10.2022  and was discharged on 12.10.2022 and the same further makes it clear that the complainant remained admitted in the hospital as an inpatient for more than 24 consecutive hours. The claim has been denied by the OP No.1 on the simple ground that no hospitalization was required and the insured would have been treated on OPD basis. The relevant portion of the repudiation letter (Annexure C-8) is reproduced as under:-

“Claim got rejected please refer remarks

 

        Treatment Possible on OPD basis- As per Part II of the policy, 1, Definition of Hospitalization:- Hospitalization means admission in a Hospital for a minimum period of 24 In patient Care and consecutive hours except for specified Day Care procedures/Treatments, where such admission could be for a period of less than 24 consecutive hours. Treatment prescribed in present admission doesn't warrant inpatient hospitalization for more than 24 hrs and also not listed under specified day care procedures/ treatments, where criteria for requirement of minimum 24 hrs hospitalization is waived off. Treating Dr statement was collected from the hospital for need of Hospitalization as per Doctor patient have high grade fever with arthralgia so need of Hospitalization is justified but insured did not have any fever spike above 99f, no electrolyte imbalance note, no fever profile is positive, no USG done for complaint of abdominal pain hence insured could be treated on OPD basis. Hence the claim stands rejected.”

4. However, the discharge summary further clearly indicates that at the time when the complainant was admitted in the hospital/OP No.2, she was diagnosed with acute febrile illness with arthralagia and the relevant portion of the discharge summary is also reproduced as under:-

“DIAGNOSIS:-

 

ACUTE FEBRILE ILLNESS WITH ARTHRALAGIA

PRESENTATION AND HOSPITAL COURSE:

 

38 years female presented to the hospital with complaint of high grade fever on & off since 3 days, headache, epigastric pain and abdominal discomfort afterward nausea, severe bodyache with polyarthralagia, burniong micturition since 2 days, oral ulcers. She got done her urine-R/M-pus cell-4-6 on 07/10/22(outside). Now admitted here for further evaluation and management. All relevant investigations were done-revealed-HB-12, TLC-3400, PLT-72000, Na-142.6, K-4.55, CRP-43.6, dengue serology was tested negative. On examination, her vitals were stable with spo2~98% on room air. During hospital stay patient was managed with intravenous fluids, antiemetic, analgesic, PPI'S and with other supportive management. Her condition gradually improved and now being discharged on request with following advice.”

 

       Thus, when it has come on record that due to the serious condition of the complainant, her hospitalization for 4 days continued and during that period, the treating doctors conducted various investigations and finding her condition stable on 12.10.2022, the  complainant was discharged with the advice to approach the hospital in case of high grade fever, vomiting, lose motion etc. immediately and this evidence led by the complainant has not been rebutted by OP No.1 with the report of medical expert indicating that no hospitalization was required for the complainant during the said period, it is clear that OP No.1 has wrongly formed opinion that the hospitalization of complainant as inpatient was not required. Moreover, the medical officer who attended the complainant and had given the treatment to the complainant was the best person to take decision on seeing the condition of the complainant, if hospitalization was required or not. whereas OP No.1 has simply repudiated the claim of the complainant by taking the opinion of some investigator who is not even a medical officer, it is safe to hold that the genuine claim of the complainant was wrongly repudiated by OP No.1 on flimsy grounds and the same amounts to deficiency in service and unfair trade practice on the part of OP No.1.

5. In view of the aforesaid discussion, it is safe to hold that the complainant has successfully proved the cause of action set up in the consumer complaint and the present consumer complaint deserves to succeed.
6. Now coming to the quantum of amount, since the complainant has proved on record the bills (Annexure C-7 (Colly.) to the tune of ₹68,898/-  indicating that out of the said amount, he had paid ₹58,648/- to OP No.2/hospital and the remaining amount was incurred by him on purchase of the medicines/tests, it is safe to hold that the insurer is liable to pay said amount to complainant alongwith interest and compensation etc.

4.        In the light of the aforesaid discussion, the present consumer complaint succeeds, the same is hereby partly allowed and OP No.1 is directed as under :-
   1. to pay ₹68,898/- to the complainant alongwith interest @ 9% per annum (simple) from the date of repudiation of the claim  i.e. 23.11.2022 onwards
   2. to pay ₹10,000/- to the complainant as compensation for causing mental agony and harassment;
   3. to pay ₹10,000/- to the complainant as costs of litigation.
5.        This order be complied with by OP No.1 within a period of 45 days from the date of receipt of certified copy thereof, failing which the amount(s) mentioned at Sr.No.(i) & (ii) above shall carry penal interest @ 12% per annum (simple) from the date of expiry of said period of 45 days, instead of 9% [mentioned at Sr.No.(i)], till realisation, over and above payment of ligation expenses.
6.        However, the consumer complaint against OP No.2 stands dismissed with no order as to costs as no cause of action has been proved against it.
7.        Pending miscellaneous application(s), if any, also stands disposed off.
8.        Certified copies of this order be sent to the parties free of charge. The file be consigned.

5/11/2024			[Pawanjit Singh] President
			[Surjeet Kaur] Member
			[Suresh Kumar Sardana] Member

cmg